| ADDRESS: 805 DEVELOPMENT DR, KINGSTON, ON K7M 4W6 TEL: 613-389-8660 EMAIL: reception@davidgouettdentistry.com
# INFORMED CONSENT FOR ENDODONTIC TREATMENT Official Clinical Data Record Submission
The goal of root canal treatment is to save a tooth that might otherwise require extraction. Although root canal treatment has a very high success rate, as with all medical and dental procedures, it is a procedure whose results cannot be guaranteed. Further, root canal treatment is performed to correct an apparent problem and occasionally an unapparent, undiagnosed or hidden problem arises. This procedure will not prevent future tooth decay, tooth fracture or gum disease, and occasionally a tooth that has had root canal treatment may require re-treatment, endodontic surgery, or tooth extraction. RISKS: ARE UNLIKELY, BUT MAY OCCUR. THEY MIGHT INCLUDE BUT ARE NOT LIMITED TO:
• | Instrument separation in the canal.
• | Blocked root canals that cannot be ideally completed.
• | Post-operative infection requiring additional treatment or the use of antibiotics.
• | Fracture, chipping, or loosening of existing tooth or crown.
• | Temporary or permanent numbness.
• | Medical problems may occur if I do not have the root canal completed.
• | Perforations (extra openings) of the canal with instruments.
• | Incomplete healing.
• | Tooth and/or root fracture that may require extraction.
• | Post-treatment discomfort.
• | Change in the bite or jaw joint difficulty (TMJ problems or TMD).
• | Reactions to anesthetics, chemicals or medications.
OTHER TREATMENT CHOICES: THE FOLLOWING OTHER TREATMENT OPTIONS MIGHT BE POSSIBLE:
• | No Treatment at all.
• | Waiting for more definitive development of symptoms.
• | Extraction: To be replaced with nothing, a denture, a bridge or an implant.
After the completion of the root canal procedure, a temp or permanent restoration will be placed. Failure to have the tooth properly restored in a timely manner (generally within 30 days) significantly increases the possibility of failure of the root canal procedure or tooth fracture. A full coverage crown is standard of care to protect the tooth.
PRINT NAME: [Full Name Response] |  | TOOTH #: [#] |  | DATE: [mm/dd/yyyy]
PATIENT SIGNATURE: [Digitally Endorsed by Patient] |  | WITNESS: [Witness Name]
© 2026 David Gouett Dentistry. This record is protected under PIPEDA and PHIPA legislation. Unauthorized disclosure of this clinical information is strictly prohibited.